1639838337 NPI number — RYLIE JO ERTL PA-C

Table of content: RYLIE JO ERTL PA-C (NPI 1639838337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639838337 NPI number — RYLIE JO ERTL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERTL
Provider First Name:
RYLIE
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLCOMB
Provider Other First Name:
RYLIE
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639838337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
491 ALLENDALE RD
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-9990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-563-0950
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 FRIENDS LANE
Provider Second Line Business Practice Location Address:
STE. 101
Provider Business Practice Location Address City Name:
NEWTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18940-1885
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-563-0950
Provider Business Practice Location Address Fax Number:
352-333-0990
Provider Enumeration Date:
12/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  MA065687 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9TUAK . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1132746-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113274600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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